Beth PRC Form

Misamis University
Ozamiz City College of Nursing & School of Midwifery

Tel. Nos.: (088) 521-0367, 521-0431 / Telefax No.: (088) 521-2917 E-mail Address: mu@mu.edu.ph
ODC Form 2A O.R. SCRUB FORM Major
Accreditation: PACUCOA
Level II First Reaccredited Status Inclusive Date of Accreditation: October 2009-October 2014 Certification: ISO 9001: 2008 Quality Management System Det Norske Veritas, The Netherlands SURGICAL SCRUB LANAO DEL NORTE PROVINCIAL HOSPITAL, Baroy, Lanao del Norte
(Hospital, Municipality/City/Province)
Prepared by: MARIBETH A. DAGATAN Student Date Performed and Time Started Patients Initials (only) Case Number PB 00-81-30 Extraction
SURGICAL PROCEDURE PERFORMED Extracapsular Cataract Lens
OR Nurse on Duty (Name and Signature)
Supervised by Clinical Instructor (Name and Signature) Mrs. Merasol O. Duyag, MAN
November 23, 2010 03:00PM
Aida G. Sagal, RN
Noted by: LORELEI D. PROCIANOS Clinical Coordinator PRC ID No. 0382092 Valid Until : May 19, 2014 October 24, 2013 Date document is signed: ___________________ Time: __________________ __________________
Approved by: CYNTHIA S. SUPERABLE Dean PRC ID No. 0135575
Valid Until :
Date document is signed: ___________________Time:
Highest Nursing Degree Earned:
MAN
Highest Nursing Degree Earned:
MAN
Misamis University
Level II First Reaccredited Status Inclusive Date of Accreditation: October 2009-October 2014 Certification: ISO 9001: 2008 Quality Management System Det Norske Veritas, The Netherlands SURGICAL SCRUB LANAO DEL NORTE PROVINCIAL HOSPITAL, Baroy, Lanao del NOrte
Prepared by: MARIBETH A. DAGATAN Student Date Performed and Time Started Patients Initials (only) Case Number AA 01-16-88
SURGICAL PROCEDURE PERFORMED Suturing
OR Nurse on Duty (Name and Signature) Kristoffer Alexius F. Birondo, RN
Supervised by Clinical Instructor (Name and Signature) Mrs. Merasol O. Duyag, MAN
August 12, 2010 10:35PM
Noted by: LORELEI D. PROCIANOS
Approved by: CYNTHIA S. SUPERABLE
Clinical Coordinator PRC ID No. 0382092 Valid Until : May 19, 2014 October 24, 2013 Date document is signed: ___________________ Time: __________________ __________________ Highest Nursing Degree Earned: MAN
Dean PRC ID No. 0135575 Valid Until : Date document is signed: ___________________Time: Highest Nursing Degree Earned: MAN
Misamis University
ODC Form 2A O.R. SCRUB FORM Major
Level II First Reaccredited Status Inclusive Date of Accreditation: October 2009-October 2014 Certification: ISO 9001: 2008 Quality Management System Det Norske Veritas, The Netherlands SURGICAL SCRUB MISAMIS OCCIDENTAL PROVINCIAL HOSPITAL, Oroquieta City
Prepared by: MARIBETH A. DAGATAN Student Date Performed and Time Started Patients Initials (only) Case Number AR 19-40-51 SURGICAL PROCEDURE PERFORMED Cesarean Section OR Nurse on Duty (Name and Signature) Supervised by Clinical Instructor (Name and Signature) Mr. Christopher A. Abellana, MAN
February 01, 2011 08:00AM
Rovi Jan Huertas, RN
Noted by: LORELEI D. PROCIANOS Clinical Coordinator
Approved by: CYNTHIA S. SUPERABLE Dean
PRC ID No. 0382092 Valid Until : May 19, 2014 October 24, 2013 Date document is signed: ___________________ Time: __________________ __________________ Highest Nursing Degree Earned: MAN
PRC ID No. 0135575
Valid Until :
Date document is signed: ___________________Time: Highest Nursing Degree Earned: MAN
Misamis University
Level II First Reaccredited Status Inclusive Date of Accreditation: October 2009-October 2014 Certification: ISO 9001: 2008 Quality Management System Det Norske Veritas, The Netherlands SURGICAL SCRUB MISAMIS OCCIDENTAL PROVINCIAL HOSPITAL, Oroquieta City
Prepared by: MARIBETH A. DAGATAN Student
Date Performed and Time Started
Patients Initials (only) Case Number CR 03-45-21
SURGICAL PROCEDURE PERFORMED Removal of Debris at the Right Hand
OR Nurse on Duty (Name and Signature) Alma Fanilag, RN
Supervised by Clinical Instructor (Name and Signature) Mr. Christopher A. Abellana, MAN
February 08, 2011 09:45AM
Noted by: LORELEI D. PROCIANOS Clinical Coordinator PRC ID No. 0382092 Valid Until : May 19, 2014 October 24, 2013 Date document is signed: ___________________ Time: __________________ __________________ Highest Nursing Degree Earned: MAN
Approved by: CYNTHIA S. SUPERABLE Dean PRC ID No. 0135575 Valid Until : Date document is signed: ___________________Time: Highest Nursing Degree Earned: MAN
Misamis University
Level II First Reaccredited Status Inclusive Date of Accreditation: October 2009-October 2014 Certification: ISO 9001: 2008 Quality Management System Det Norske Veritas, The Netherlands
SURGICAL SCRUB MAYOR HILARION A. RAMIRO SR. REGIONAL TRAINING AND TEACHING HOSPITAL, Ozamiz City Prepared by: MARIBETH A. DAGATAN Student
Date Performed and Time Started
Patients Initials (only) Case Number MCJ 11-00-49
SURGICAL PROCEDURE PERFORMED Dilation and Curettage
OR Nurse on Duty (Name and Signature) Ma.Chuchie C. Dela Pena, RM
Supervised by Clinical Instructor (Name and Signature) Mrs. Denise Katherine A. Amora, MN
January 18, 2010 01:20PM
Noted by: LORELEI D. PROCIANOS Clinical Coordinator PRC ID No. 0382092 Valid Until : May 19, 2014 October 24, 2013 Date document is signed: ___________________ Time: __________________ __________________ Highest Nursing Degree Earned: MAN
Approved by: CYNTHIA S. SUPERABLE Dean PRC ID No. 0135575 Valid Until : Date document is signed: ___________________Time: Highest Nursing Degree Earned: MAN
Misamis University
ODC Form 1A ACTUAL DELIVERY FORM
Level II First Reaccredited Status Inclusive Date of Accreditation: October 2009-October 2014 Certification: ISO 9001: 2008 Quality Management System Det Norske Veritas, The Netherlands ACTUAL DELIVERY in Lanao del Norte Provincial Hospital, Baroy, Lanao del Norte
Prepared by:
MARIBETH A. DAGATAN Student Date Performed and Time of Delivery August 11, 2010 01:08PM August 17, 2010 08:20AM Patients Initials (only) Case Number AE 00-39-91 OR 00-40-10 PROCEDURE PERFORMED DR Nurse on Duty (Name and Signature) (If Midwife on Duty, Signature not Required) Josefina F. Apat, MN Josefina F. Apat, MN Supervised by Clinical Instructor (Name and Signature) Mrs. Merasol O. Duyag, MAN Mrs. Merasol O. Duyag, MAN
Handled Delivery Handled Delivery
Noted by: MARIA CARIDAD L. MUTIA Clinical Coordinator PRC ID No. 0382092 Valid Until : May 19, 2014 October 24, 2013 Date document is signed: ___________________ Time: __________________ __________________ Highest Nursing Degree Earned: MAN
Valid Until :
Misamis University
ODC Form 1A ACTUAL DELIVERY FORM
ACTUAL DELIVERY in Mayor Hilarion A. Ramiro Sr. Regional Training and Teaching Hospital, Ozamiz City
Prepared by: MARIBETH A. DAGATAN Student Date Performed and Time of Delivery August 4, 2009 11:50AM January 27, 2010 08:46AM April 09, 2010 03:24PM Patients Initials (only) Case Number MJS 04-15-93 KM 01-56-18 MCT 11-33-62 PROCEDURE PERFORMED DR Nurse on Duty (Name and Signature) (If Midwife on Duty, Signature not Required) Ma. Chuchie C. Dela Pena, RM Ma. Chuchie C. Dela Pena,RM Ma. Chuchie C. Dela Pena, RM Supervised by Clinical Instructor (Name and Signature) Mrs. Denise Katherine A. Amora, MN Mrs. Denise Katherine A. Amora, MN Mrs. Denise Katherine A. Amora, MN
Handled Delivery Handled Delivery Handled Delivery
Noted by: MARIA CARIDAD L. MUTIA Clinical Coordinator PRC ID No. 0382092 Valid Until : May 19, 2014 October 24, 2013 Date document is signed: ___________________ Time: __________________ __________________ Highest Nursing Degree Earned: MAN
Valid Until :
Misamis University
ODC Form 1B ASSISTED DELIVERY FORM
ACTUAL DELIVERY in Mayor Hilarion A. Ramiro Sr. Regional Training and Teaching Hospital, Ozamiz City
Prepared by: MARIBETH . DAGATAN Student Date Performed and Time of Delivery July 29, 2009 10:18AM January 19, 2010 11:49AM January 25, 2010 7:44AM April 9, 2010 6:45AM May 31, 2010 2:09PM Noted by: MARIA CARIDAD L. MUTIA Clinical Coordinator PRC ID No. 0382092 Valid Until : May 19, 2014 October 24, 2013 Date document is signed: ___________________ Time: __________________ __________________ Highest Nursing Degree Earned: MAN Patients Initials (only) Case Number GMJ 10-32-18 OM 11-00-88 PM 09-71-09 DV 07-06-88 NA 11-56-92 Assisted Delivery Assisted Delivery Assisted Delivery Assisted Delivery PROCEDURE PERFORMED DR Nurse on Duty (Name and Signature) (If Midwife on Duty, Signature not Required) Ma. Chuchie C. Dela Pena,RM Ma. Chuchie C. Dela Pena,RM Ma. Chuchie C. Dela Pena,RM Ma. Chuchie C. Dela Pena,RM Ma. Chuchie C. Dela Pena,RM Approved by: CYNTHIA S. SUPERABLE Dean PRC ID No. 0135575 Supervised by Clinical Instructor (Name and Signature) Mrs. Denise Katherine Amora, MN Mrs. Denise Katherine Amora, MN Mrs. Denise Katherine Amora, MN Mrs. Denise Katherine Amora, MN Mrs. Denise Katherine Amora, MN A. A. A. A. A.
Assisted Delivery
Valid Until :
Date document is signed: ___________________Time: Highest Nursing Degree Earned:

ODC Form 1C CORD CARE FORM
MAN
Misamis University

IMMEDIATE NEWBORN CORD CARE in Mayor Hilarion A. Ramiro Sr. Regional Training and Teaching Hospital, Ozamiz City Prepared by: MARIBETH A. DAGATAN Student Date Performed and Time of Delivery July 28, 2009 12:01PM August 3, 2009 2:01PM January 20, 2010 9:08AM January 26, 2010 08:30AM January 27, 2010 8:46AM Noted by: MARIA CARIDAD L. MUTIA Clinical Coordinator PRC ID No. 0382092 Valid Until : May 19, 2014 October 24, 2013 Date document is signed: ___________________ Time: __________________ __________________ Highest Nursing Degree Earned: MAN Patients Initials (only) Case Number PMC 10-02-12 GTA 10-33-42 GI 08-80-82 AL 11-03-55 MK 01-56-18 DR Nurse on Duty (Name and Signature) (If Midwife on Duty, Signature not Required) Ma. Chuchie C. Dela Pena,RM Ma. Chuchie C. Dela Pena,RM Ma. Chuchie C. Dela Pena,RM Ma. Chuchie C. Dela Pena,RM Ma. Chuchie C. Dela Pena,RM Approved by: CYNTHIA S. SUPERABLE Dean PRC ID No. 0135575 Supervised by Clinical Instructor (Name and Signature) Mrs. Denise Katherine A. Amora, MN Mrs. Denise Katherine A. Amora, MN Mrs. Denise Katherine A. Amora, MN Mrs. Denise Katherine A. Amora, MN Mrs. Denise Katherine A. Amora, MN
PROCEDURE PERFORMED Cord Care Cord Care Cord Care Cord Care Cord Care
Valid Until :

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Misamis University

Ozamiz City College of Nursing & School of Midwifery

ODC Form 2A O.R. SCRUB FORM Major

SURGICAL PROCEDURE PERFORMED Extracapsular Cataract Lens

OR Nurse on Duty (Name and Signature)

November 23, 2010 03:00PM

Approved by: CYNTHIA S. SUPERABLE Dean PRC ID No. 0135575

Date document is signed: ___________________Time:

Highest Nursing Degree Earned:

Highest Nursing Degree Earned:

SURGICAL PROCEDURE PERFORMED Suturing

OR Nurse on Duty (Name and Signature) Kristoffer Alexius F. Birondo, RN

August 12, 2010 10:35PM

Noted by: LORELEI D. PROCIANOS

Approved by: CYNTHIA S. SUPERABLE

ODC Form 2A O.R. SCRUB FORM Major

February 01, 2011 08:00AM

Rovi Jan Huertas, RN

Noted by: LORELEI D. PROCIANOS Clinical Coordinator

Approved by: CYNTHIA S. SUPERABLE Dean

PRC ID No. 0135575

Date document is signed: ___________________Time: Highest Nursing Degree Earned: MAN

Prepared by: MARIBETH A. DAGATAN Student

Date Performed and Time Started

Patients Initials (only) Case Number CR 03-45-21

SURGICAL PROCEDURE PERFORMED Removal of Debris at the Right Hand

OR Nurse on Duty (Name and Signature) Alma Fanilag, RN

February 08, 2011 09:45AM

Date Performed and Time Started

Patients Initials (only) Case Number MCJ 11-00-49

SURGICAL PROCEDURE PERFORMED Dilation and Curettage

OR Nurse on Duty (Name and Signature) Ma.Chuchie C. Dela Pena, RM

January 18, 2010 01:20PM

ODC Form 1A ACTUAL DELIVERY FORM

Handled Delivery Handled Delivery

Approved by: CYNTHIA S. SUPERABLE Dean PRC ID No. 0135575

Date document is signed: ___________________Time: Highest Nursing Degree Earned: MAN

ODC Form 1A ACTUAL DELIVERY FORM

Handled Delivery Handled Delivery Handled Delivery

Approved by: CYNTHIA S. SUPERABLE Dean PRC ID No. 0135575

Date document is signed: ___________________Time: Highest Nursing Degree Earned: MAN

ODC Form 1B ASSISTED DELIVERY FORM

Date document is signed: ___________________Time: Highest Nursing Degree Earned:

Ozamiz City College of Nursing & School of Midwifery

Date document is signed: ___________________Time: Highest Nursing Degree Earned: MAN

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